Patient Safety Tip
of the Week
January 16,
2018 Just the Fax, Ma’am
We’ll bet the majority of our
readers are not old enough to remember Sgt. Joe Friday’s catchphrase “Just the
facts, ma’am” on the TV show “Dragnet”. And those same readers probably
recognize fax machines as an anachronism. That is, unless they work in a
doctor’s office or a hospital! We were shocked to see and hear the recent disclosures
about how rampant use of fax machines continues to be in doctors’ offices (Kliff
2017, Hill
2017).
Sarah Kliff and colleagues did a
podcast on faxing in doctors’ offices on Vox’s “The Impact” series (Kliff
2017). In Adriene Hill’s interview with Vox’s Sarah Kliff (Hill
2017) it was noted that “Kliff found that it was
a combination of culture and well-intended policy that's lead to the fax
machine being a staple in doctors' offices.” Kliff
had spent a lot of time in backrooms of physician offices and found fax
machines “buzzing all the time”. In fact, it appeared that most communication
between hospitals and physician offices was via fax rather than, for example,
email. Kliff noted that use of faxing has persisted
despite 90+% of physician offices now using electronic medical records. Of
course, the crux of the problem is lack of interoperability. Simply put, many
electronic medical record systems are not interconnected to each other. Kliff describes the situation now as “doctors are printing
out their own electronic records, faxing it to another doctor office, and then
that doctor uploads the printout of the record into their own electronic
record.”
The actual podcast (Kliff
2017) runs about 24 minutes and is quite entertaining and points out
the most salient root cause of the problem: business competition. The podcast
starts out in a backoffice setting where the fax
machine is busy sending or receiving faxes. Sometimes the machine is busy when
attempting to send out a fax. A staff member notes that sometimes the faxes are
blurry and she has to start the whole process over
again. And sometimes the faxes “just don’t show up at all”. It “means calling
them and asking them to send records”. Practices often keep thick folders of
records they are still waiting to receive. One staff member “estimates that 80%
of the faxes she sends need some sort of human intervention”.
Kliff interviewed staff and
physicians in several practices. They noted how patients lose time off work
because records never came. Often weeks of phone calls and badgering are
required to get records and they often have to
reschedule appointments because records had not been received. Highlighted were
instances where the only way to communicate records from one floor or
department of a hospital to another was via fax (because the electronic medical
record systems were not capable of interoperability).
Staff felt they could do so much more if they didn’t waste time with faxes.
Kliff then goes on to discuss why
faxing, variously described as “the cockroach of American medicine” or “clunky”
refuses to die. Some office staff say “oh, it’s a HIPAA thing”. Kliff appropriately points out that faxing is not very secure and that HIPAA-secure email is an alternative that is
available. She then discusses how the HITECH Act of 2009 “set out to kill the
fax”. That act, of course, provided the financial stimulus for widespread
adoption of electronic medical records. But there was a fatal flaw: competing
businesses guard their info. And that proclivity to hoard information applied
both to EMR vendors and to hospitals/practices that were competing for
“customers”. EMR vendors did not want to share their secrets with their
competitors by allowing sharing of data. And hospitals “down
the street” from each other are competing for the same patients and don’t want
to share information about those patients.
She interviewed David Blumenthal (former National
Coordinator for Health Information Technology), who noted talk is often about
“private sector, competition, and choice“ as key
principles by which our healthcare system should operate but that raises
problems for patient care. Kliff quotes another former
ONC director, Farzad Mostishari, “the only way to kill fax is to outlaw it”. But
the podcast goes on to discuss that the current administration thinks
otherwise, that we need fewer mandates and wants to turn more over to the
private sector and “get government out of the way”.
It’s a fascinating podcast and shows that the fax has not
died. Rather it seems to still be a major, if not the major, mode of transmitting patient information today. It
estimates that billions of patient care-related documents are still transmitted
by fax today.
Actually, we are not so surprised.
Sometimes when we come to a hospital we’ll wager a friendly bet that we will
find certain things (we only bet on things we know are sure winners!). One of
those is that we will find alarms that have either been disabled or had their
volume altered to make them poorly audible or their parameters have been set so
wide that they are unlikely to alarm for important occurrences. Another is that
we will find several risk factors for patient suicide. And a third is that we
will find examples of problems related
to sending or receiving faxed orders or other patient-related material.
So, obviously, it’s
worth repeating some of the caveats we raised in our June 19, 2012 Patient
Safety Tip of the Week “More
Problems with Faxed Orders” and other columns. The problem we have
mentioned most often is the missed
decimal point (where lines or smudge during fax transmission and printing
obscures a decimal point) and the patient receives a 10x overdose of the
medication. (In our September 9, 2008 Patient Safety Tip of the Week “Less
is More….and Do You Really Need that Decimal?” we cautioned against even using
a decimal point when the fraction following the decimal point is clinically
irrelevant because that decimal point may be overlooked, especially in faxed
orders.) The opposite, of course, may also occur where a smudge on the fax
looks like a decimal point (the phantom
decimal point) so the patient receives one-tenth the intended amount.
But we’ve also mentioned the case where 2 sheets put into a fax machine stick
together and thus only one sheet gets transmitted (see our January 18, 2011
Patient Safety Tip of the Week “More
on Medication Errors in Long-Term Care” where we cited such an example from
ISMP 2010).
Unless you have a cover fax sheet that says “3 pages (cover sheet plus 2
others)” the receiving party may not realize that they are missing a page.
We’ve also seen cases where faxes on multiple patients are sent out at the same time and the
receiving party does not recognize that the second sheet is actually for a
different patient (see our January 18, 2011 Patient Safety Tip of the Week “More
on Medication Errors in Long-Term Care”).
Just as with handwritten orders, on a faxed order with a drug ending in the letter “L” if there
is insufficient space between the “L” and the next number, the receiver may
think the “L” is actually a “1” (one) and give a dose
10 times too high. And dangerous
abbreviations may show up even more frequently on faxed orders than orders
written on-site because the provider is more likely to have access to the “do
not use” abbreviation list when on-site.
Another mistake is when a person faxes documents that have
information on both sides and does not realize that only one side of each page is being faxed.
And remember when you are sending a fax that some elements (eg.
text in a different color) may fail to be seen when transmitted. Or that highlighted items (eg.
items you tied to stress with a yellow highlighter) may appear blacked out on the received fax!
(Reminds me of the time in college when I asked a friend to send me his notes
from a class I had missed so I could study for a test the next day. He faxed
them and all the important stuff, which he had highlighted with a highlighting marker,
was blacked out on the fax!!!).
And one of the most egregious errors of all – faxing to the
wrong phone number (the misdirected fax).
Ever get a call from the local supermarket that you faxed them a sheet with PHI
on it? Your HIPAA compliance officer and risk manager will turn gray when that
call comes in! See the discussion at the end of this column.
ISMP Canada (ISMP
Canada 2012) came up with a new fax error – the truncation error. They provide a great example of a faxed order
for “dalteparin” where the “da” gets cut off in the
fax and the “lt” looks like an “H” on the fax,
resulting in what clearly looks like an order for “Heparin”. Click on the link
above and you’ll see both the faxed prescription and the original.
Note that prescription has lots of other bad errors on it.
It uses the do-not-use abbreviation “U” (for units) as well as 2 other
abbreviations that should be avoided (“SQ” for subcutaneous and “QD” for once
daily). It has a different dose written above and crossed out. And it does not
have listed the indication for the drug. It also has an illegible word
following the “QD” (is it nitely? or is it a
provider’s signature?). And there is nothing on the prescription to indicate
the duration of therapy, amount to be dispensed, whether it should be refilled,
etc. Who would have thought one prescription could be used as a primer for
medication errors!
ISMP Canada notes the importance of reviewing copies of the
fax you send or the one you receive. For instance, in the case given one might
have noticed that the name of the hospital was also truncated, which might have
been a clue that the medication name was truncated. They also note in the
example given that the dosing frequency would have been unusual for heparin (it
is usually given twice daily or three times daily rather than once daily),
perhaps being another clue to the receiver that there was an error. They also
note that including both the generic and brand names on the prescription would
have provided another clue to the error. They note the importance of engaging
the patient to be on the lookout for errors as well.
ISMP Canada lists multiple good recommendations for dealing
with faxed orders in their alert. We’ve added some of our own recommendations:
- Try to avoid receiving
faxed orders whenever possible (eg. remote CPOE
may obviate the need for faxed orders). Note that even verbal orders,
where the recipient should be doing “readback” with the ordering provider
and clarifying issues, may be preferable to fax in many cases (see our
January 10, 2012 Patient Safety Tip of the Week “Verbal
Orders”).
- When sending faxed orders
always include a cover sheet that specifies the number of sheets being
sent and clearly specifies whether the cover sheet is included in that
number.
- Similarly, when receiving
faxed orders always require a cover sheet that specifies the number of
sheets being faxed.
- When faxing, make sure you
are not missing information on 2-sided sheets.
- Always ensure that the
glass screen on your fax machine is well cleaned and does not have smudges
on it.
- Make sure your documents
are correctly aligned when faxing so that important information does not
get truncated.
- Make sure your printer/fax
has sufficient ink/toner.
- Be especially wary if your
original has information in fonts or colors that may not be seen clearly.
- Remember that some faxes
received will fade over time (especially with older fax machines that use
thermal paper). So be sure you copy those faxes into higher quality paper
or scan them into your electronic medical record.
- Consider calling the
person faxing to get verbal clarification of all orders. (In our January
10, 2012 Patient Safety Tip of the Week “Verbal
Orders” we noted that, even though we always discourage verbal orders,
they do have the advantage of 2 individuals being able to clarify issues).
- Never send faxed orders on
more than one patient at a time.
- Make sure that the
patient’s identifying information (at least two unique identifiers) is
clearly provided on every sheet being faxed.
- Only use originals for
faxing. Don’t use carbon copies or NCR paper copies as the sheets for
faxing.
- Make sure the phone number
to which you are faxing is the correct one.
- Other good prescribing
procedures always apply (don’t use dangerous abbreviations, don’t add a
trailing zero after a decimal point, always provide the indication for the
drug, leave sufficient space after a drug name ending in “L”, etc.).
- Always review received
faxes for flaws (smudges, truncation, lost segments, etc.)
You should have an educational program for all your staff
involved in sending and receiving faxed orders (nurses, physicians, clerical
staff, etc.). Remember, telling stories about real-life cases where such errors
led to bad outcomes is much more effective than just telling them facts and
statistics. Tell them one of the stories about a patient getting a 10-fold
overdose or the one where a patient got 26 medications (13 of her own and 13
from the sheet faxed in the same batch on a different patient as in our January
18, 2011 Patient Safety Tip of the Week “More
on Medication Errors in Long-Term Care”).
And don’t forget that faxing errors don’t just apply to
medication orders. Most of the same concerns apply to any patient related
material that may be faxed.
There are numerous examples of misdirected fax transmissions containing personal health
information. These are often one-time errors but amazingly there are numerous
examples in the media of continued recurrences over long periods of time. In
one instance (ANewsVanIsland 2011) a person has received at
least one such fax per week for over 10 years!!! That person’s phone number was
one digit different than the fax number for a medical clinic. Think of all the
times you have dialed the wrong phone number and how easy that would be to do
when sending a fax.
One of the typical recommendations for avoiding staff keying
in the wrong fax number is to use pre-programmed fax numbers. However, that
practice has its own set of unintended consequences in that those fax numbers
need to be up to date. We’ve seen faxes sent to old fax numbers after a
physician has moved to a new office and even faxes sent to physicians who have
been deceased for four years! And hospital computer systems often have the
wrong physician listed as primary care physician, often leading to faxes being
sent to the wrong PCP.
Both AHIMA (Davis
2006) and HIMSS (Demster
2007) had good guidelines on sending and receiving personal health
information via fax. It appears that neither of these documents is currently available but you may wish to search the AHIMA and HIMSS websites
for updates. Some of the highlights from those original guidelines are still
quite valid:
- First of all have a policy on fax transmissions and make sure
you educate everyone on it. For many employees it should be included in
the annual reorientation session or competency assessment.
- Make sure your fax
machines are in secure places.
- Always take reasonable
steps to ensure the fax is being sent to the appropriate destination.
- Make sure someone is
expecting your fax at the receiving end.
- Staff should always double
check the recipient’s fax number before pressing the send button. The
AHIMA document notes some hospitals use a brightly colored sticker on the
fax machine to remind staff of appropriate procedures.
- Make sure you send a cover
page that indicates the number of pages being sent, the name and phone
number of the sender, a confidentiality notice, and instructions of what
to do if you have received the fax in error (eg.
destroying the documents or sending them back to the sender). The HIMSS
document has copies of such cover pages.
- Remind those to whom you
frequently (or infrequently!) fax that they need to let you know of any
change in their fax number.
- Update your pre-programmed
fax numbers on a regular basis.
- When you enter a new fax
number or update a fax number do a “test” fax to ensure it is going to the
correct destination.
- Better yet before you fax make a phone call to confirm the correct fax
number and ensure that someone is at the receiving end to pick up the fax
so confidential material won’t be left sitting unattended at the receiving
end.
- Provide instructions on
what to do if the fax transmission fails.
- Consider all misdirected
faxes as reportable events and do at least a mini-RCA to identify root
causes and contributing factors. Your policy should also define whom you
need to notify (including patients) in such cases.
- Remove all received faxes
promptly and get them to the appropriate party.
- Keep fax logs for both
sent and received faxes.
- Have a person assigned to
audit (via random samples) both faxes sent and received for adherence to
your guidelines.
Another point to remember: just because your fax machine
indicated your sent fax was received at the number you sent it to does not mean
that (1) it was printed out completely and legibly without smudges, etc. and
(2) it reached the person for whom it was intended.
And often not mentioned is the fact that copies of what you
copied or faxed may remain in the memory
or hard drive of your fax machine. We remember a situation where the local
police department donated some old fax machines to charity and confidential
police records were found in the memory of those machines! The same could
obviously happen with a patient’s personal health information on it.
Lastly, the best
solution is not to fax at all! As electronic medical record systems are
evolving, check to see what your capabilities are for exporting or importing information
from other EMR’s. We’ve seen many examples where such capabilities exist, yet
practices persist in using the fax machine out of habit. Enabling faxing from
within EMR/EHR systems can also improve productivity, security and HIPAA
compliance. Similarly, in those areas where regional health information
exchanges (HIE’s) have been established, use your connectivity with those HIE’s
to share data.
References:
Hill A, McHenry S. Why your doctor still relies on fax
machines. Marketplace 2017; December 27, 2017
https://www.marketplace.org/2017/12/27/health-care/why-your-doctor-still-relies-fax-machines
Kliff S, Pinkerton B, Weinberger
J, Drozdowska A. It’s 2017. Why does medicine still
run on fax machines? Vox “The Impact” (podcast) 2017; October 30, 2017
https://www.vox.com/2017/10/30/16387306/american-medicine-healthcare-fax-machine
ISMP (Institute for Safe Medication Practices). Order
scanning systems (and fax machines) may pull multiple pages through the scanner
at the same time, leading to drug omissions. ISMP Medication Safety Alert
(Nurse Advise-ERR) 2010; 8(11): 1-2
http://www.ismp.org/newsletters/nursing/default.asp
ISMP Canada. ALERT:
Medication Mix-up with a Faxed Prescription. ISMP Canada Safety Bulletin 2012;
12(6): 1-3 June 5, 2012
ANewsVanIsland. Medical Records
Shared with Roofer. Mar 1, 2011
http://www.youtube.com/watch?v=6z0eIs8LaxM
Davis, Nancy, et al..
"Facsimile Transmission of Health Information." (AHIMA Practice
Brief, updated August 2006).
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_031811.hcsp?dDocName=bok1_031811
Demster B. HIMSS Privacy and Security
Toolkit. Managing Information Privacy & Security in Healthcare.
Communication Tools. January 2007
http://www.himss.org/content/files/CPRIToolkit/version6/v7/D80_Communication_Tools.pdf
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